Comparative Study of Preoperative Sagittal Spinal Pelvic Alignment in Patients with Cervical Spondylotic Radiculopathy, Ossification of the Posterior Longitudinal Ligament, and Cervical Spondylotic Myelopathy.

OBJECTIVES: Cervical spondylosis may lead to changes in the sagittal parameters of the neck and trigger compensatory alterations in systemic sagittal parameters. However, there is currently a dearth of comparative research on the changes and compensatory alterations to sagittal parameters resulting from different types of cervical spondylosis. This study compared the preoperative sagittal alignment sequences among patients with cervical spondylotic radiculopathy (CSR), ossification of the posterior longitudinal ligament (OPLL), and cervical spondylotic myelopathy (CSM) caused by factors resulting from non-OPLL factors. MATERIALS AND METHODS: Full length lateral X-ray of the spine and cervical computed tomography (CT) of 256 patients (134 men, 122 women; mean age, 56.9 ± 9.5 years) were analyzed retrospectively. A total of 4096 radiomics features were measured through the lateral X-ray by two spinal surgeons with extensive experience. The clinical symptoms measures were the Japanese Orthopaedic Association (JOA) score, number of hand actions in 10 s, hand-grip strength, visual analog scale (VAS) score. Normally distributed data was compared using one-way analysis of variance (ANOVA) for parametric variables and χ2 test were used to analyze the categorical data. RESULTS: In the OPLL group, the C2-C7 Cobb angle was greater than in the CSR and CSM groups (19.8 ± 10.4°, 13.3 ± 10.3°, and 13.9 ± 9.9°, respectively, p < 0.001). Additionally, the C7-S1 SVA measure was found to be situated in the anterior portion with regards to the CSM and CSR groups (19.7 ± 58.4°, -6.3 ± 34.3° and -26.3 ± 32.9°, p < 0.001). Moreover, the number of individuals with C7-S1 SVA >50 mm was significantly larger than the CSM group (26/69, 11/83, p < 0.001). In the CSR group, the TPA demonstrated smaller values compared to the OPLL group (8.8 ± 8.5°, 12.7 ± 10.2°, p < 0.001). Furthermore, the SSA was comparatively smaller as opposed to both the OPLL and CSM groups (49.6 ± 11.2°, 54.2 ± 10.8° and 54.3 ± 9.3°, p < 0.05). CONCLUSION: Patients with OPLL exhibit greater cervical lordosis than those with CSR and CSM. However, OPLL is more likely to result in spinal imbalance when compared to the CSM group. Furthermore, OPLL and CSM patients exhibit anterior trunk inclination and worse global spine sagittal parameters in comparison to CSR patients.

Biomechanical Effects of Multi-segment Fixation on Lumbar Spine and Sacroiliac Joints: A Finite Element Analysis.

OBJECTIVE: Spine fixation surgery affects the biomechanical environment in the sacroiliac joint (SIJ), which may lead to the SIJ pain or degeneration after surgery. The purpose of this study is to determine the impact of the number and position of fixed segments on the SIJs and provide references for surgeons to plan fixation levels and enhance surgical outcomes. METHODS: The intact lumbar-pelvis finite element (FE) models and 11 fixation FE models with different number and position of fixed segments were developed based on CT images. A 400N follower load and 10° range of motion (ROM) of the spine were applied to the superior endplate of L1 to simulate the flexion, extension, bending and torsion motion after surgery. The peak stress on the SIJs, lumbar intervertebral discs, screws and rods were calculated to evaluate the biomechanical effects of fixation procedures. RESULTS: With the lowermost instrumented vertebra (LIV) of L5 or S1, the peak stress on SIJs increased with the number of fixed segments increasing. The flexion motion led to the greater von Mises stress on SIJ compared with other load conditions. Compared with the intact model, peak stress on all fixed intervertebral discs was reduced in the models with less than three fixed segments, and it increased in the models with more than three fixed segments. The stress on the SIJ was extremely high in the models with all segments from L1 to L5 fixed, including L1-L5, L1-S1 and L1-S2 fixation models. The stress on the segment adjacent to the fixed segments was significant higher compared to that in the intact model. The peak stress on rods and screws also increased with the number of fixed segments increasing in the flexion, extension and bending motion, and the bending and flexion motions led to the greater von Mises stress on SIJs. CONCLUSION: Short-term fixation (≤2 segments) did not increase the stress on the SIJs significantly, while long-term segment fixation (≥4 segments) led to greater stress on the SIJs especially when all the L1-L5 segments were fixed. Unfixed lumbar segments compensated the ROM loss of the fixed segments, and the preservation of lumbar spine mobility would reduce the risks of SIJ degeneration.

Can the 6-minute Walking Test Assess Ambulatory Function Impairment in Patients with Cervical Spondylotic Myelopathy?

STUDY DESIGN: Prospective cohort study. OBJECTIVE: Investigating the ability of a 6-minute walking test (6MWT) to assess functional status in patients with cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: The 6MWT provides an objective assessment of a patient's ability to walk. There is the potential for its application to the assessment of functional status in patients with CSM. MATERIALS AND METHODS: One hundred and thirty-five patients from our institution were prospectively enrolled from July 2022 to August 2023. A control group of age- and sex-matched healthy individuals was established. The 6MWT was conducted in strict accordance with established guidelines. The Nurick score, the Prolo score, the Cooper-myelopathy-scale score (CMS), the Japanese Orthopedic Association score (JOA) and the European-myelopathy-scale score (EMS) were assessed preoperatively. Visual Analog Scale (VAS) for pain or numbness and Oswestry Neck Disability Index (NDI) were also collected. Radiographic parameters were measured and recorded. Continuous variables between patients and controls were compared by applying the t-test. The chi-square test was used to compare gender ratios between groups. Pearson's correlation analysis was used to analyze the association between continuous variables and ordinal variables. Subgroups of CSM patients were analyzed according to global spinal alignment types, based on whether the SVA was greater than or equal to 50 mm. Clinical scores and imaging parameters were compared by t-test. RESULTS: The preoperative 6-minute walking distance (6MWD) of CSM patients was 309.34 ± 116.71 m, which was significantly lower than that of the controls (464.30 ± 52.59 m, P<.01). The 6MWD was significantly correlated with scores on all clinical scales except the VAS. CMS Lower extremity score had the strongest correlation with preoperative 6MWD in CSM patients (r=-.794 , P<.01). Of the sagittal alignment parameters, only C7 sagittal vertical axis (SVA) and T1 slope were significantly correlated with 6MWD(r=-.510,-0.360, respectively). CSM patients with SVA greater than 50 mm had significantly lower 6MWD than CSM patients with SVA less than or equal to 50 mm (168.00 ± 137.26 vs 346.24 ± 84.27 m, P<.01). CONCLUSIONS: The 6MWD of CSM patients was significantly lower than that of the healthy population and correlated well with commonly used clinical scales. The 6MWD can potentially assist in the assessment of functional status in patients with CSM.

Classification of the Congenital Defect of the Lumbar Facet Joint: Case Report and Literature Review.

BACKGROUND: Congenital lumbar facet joint defect is a rare congenital developmental disorder with only a few reported cases in the literature, primarily affecting the L5-S1 segments. This study reports the first case of a defect in the left L3 inferior articular process; and presents a review of the existing literature on the subject, proposes a classification system, and validates the inter-observer and intra-observer reliability of this classification system. CASE PRESENTATION: A 14-year-old boy presented to our orthopedic clinic with persistent lower back pain for 1 month. Imaging analysis, including CT scans, 3D reconstruction, and MRI, revealed a congenital lumbar facet joint defect at the L3 level, which has not been reported. Conservative treatment resulted in a significant improvement in his symptoms, and he is currently under follow-up care. CONCLUSION: Congenital defect of the lumbar facet joint is a rare spinal condition. This article reports the first patient with a defect in the left L3 inferior articular process and conducts a comprehensive literature review, proposing a classification of articular process defects into five types. The two most common types are Types B and C. We have demonstrated that this system is reliable and reproducible and have described the treatment of each type.

Hysterectomy - a possible risk factor for operative intervention in female patients for degenerative lumbar spine conditions: a case control and cohort study.

BACKGROUND CONTEXT: Researchers have recently linked hysterectomy, which alters sex hormone levels, to diseases like osteoporosis, lumbar spondylolisthesis, hypertension and diabetes etc. However, the association between hysterectomy and lumbar disc herniation (LDH)/lumbar spinal stenosis (LSS) remains unclarified. PURPOSE: To determine whether there is a correlation between hysterectomy and surgical intervention for LDH/LSS in women, further substantiated through imaging and clinical research. STUDY DESIGN: A case control and cohort study. PATIENT SAMPLE: The study group comprised 1202 female patients aged 45 and older who had undergone operative treatment due to LDH/LSS (825 for LDH and 377 for LSS), and the comparison group comprised 1168 females without lumbar diseases who visited health examination clinic during the same period. One hundred and 2 hysterectomized patients were further selected (Hysterectomy cohort) and matched approximately with the control cohort at a 1:2 ratio from the study group with a minimum follow-up of 2 years. OUTCOME MEASURES: Odds Ratios (ORs) and 95% Confidence Intervals (CIs) were calculated to assess the association between hysterectomy and surgical intervention for LDH/LSS in women after adjusted by confounding factors. Patients from both the hysterectomy and control cohorts underwent a comprehensive assessment. This assessment included the evaluation of several parameters: the functional cross-sectional area, fat infiltration rate, relative functional cross-sectional area of the lumbar paravertebral muscles, facet joint degeneration grade, cartilage endplate damage, Modic changes for the L3/4-L5/S1 segments, Pfirrmann grade of lumbar disc degeneration, and disc height index for the L1/2-L5/S1 segments. Additionally, the Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) scores were recorded preoperatively and at the last follow-up. METHODS: Associations between hysterectomy and patients treated surgically for LDH or LSS were analyzed using multivariate binomial logistic regression analysis. Lumbar X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) were used to evaluate the imaging variables. Imaging and clinical variables were compared. RESULTS: Hysterectomized women were associated with requiring surgery due to LDH/LSS, with ORs of 2.613 (p<.001) and 2.084 (p=.006), respectively. The imaging evaluation further revealed that the hysterectomy cohort had more severe degeneration of the paraspinal muscles, facet joints, endplates, and intervertebral discs, Modic changes at L3/4-L5/S1 segments, and intervertebral height reduction at L1/2-L5/S1 segments when compared to the control cohort (p<.01). Compared to the control cohort, the hysterectomy cohort exhibited higher preoperative and last follow-up VAS scores for low back pain, and last follow-up JOA scores (p<.01). CONCLUSIONS: Based on the findings of this study, it seems that women who have had a hysterectomy are correlated with requiring surgical intervention due to LDH/LSS. Imaging and clinical studies also indicate that hysterectomized patients exhibited more severe lumbar degeneration and back pain.

The Comparison between Spinal Facet Joint Toothed Plate and Traditional Pedicle Screw-rod on Reduction of Thoracolumbar Fracture.

OBJECTIVE: Thoracolumbar fractures are one of the most common fractures in clinical practice. Surgical intervention is recommended to restore spinal alignment or decompress the nerves when there are unstable fractures or neurological injuries. However, after excessive forward thrust force restoration, facet joint dislocation often occurs between the upper vertebra and the fractured vertebra, which usually leads to unsatisfactory reduction outcomes. Herein, we propose a novel spinal facet joint toothed plate to assist in fracture reduction. The purpose of this study is to evaluate the effectiveness of the new spinal facet joint toothed plate in preventing facet joint dislocation, and its advantages compared to traditional pedicle screw-rod decompression. METHODS: A total of 26 patients in the toothed plate group and 93 patients in the traditional group who experienced thoracolumbar fracture with reduction were retrospectively included. Relevant patients' information and clinical parameters were collected. Furthermore, visual analogue scores (VAS) scores and Oswestry disability index (ODI) scores were also collected. Moreover, imaging parameters were calculated based on radiographs. Correlated data were analyzed by χ2 test and t test. RESULTS: All patients in this study had no postoperative complications. Postoperative VAS scores and ODI scores (p < 0.001) were statistically significant (p < 0.001) in both groups compared with preoperative scores and further decreased (p < 0.001) at final follow-up. In addition, the postoperative vertebral margin ratio (VMR) (p < 0.001) and vertebral angle of the injured vertebrae (p < 0.001) were significantly improved compared with the preoperative period. There were no significant differences in postoperative VAS scores and ODI scores between the two groups. However, toothed plate reduction significantly improved the VMR (p < 0.05) and vertebral angle (p < 0.05) compared with conventional reduction. Ultimately, the total screw accuracy was 98.72% (sum of levels 0 and I), with 100% screw accuracy in the segment related to the tooth plate in the tooth plate group. The dislocation rate was higher in the conventional group (6.45%) than in the new serrated plate repositioning group (0.00%). CONCLUSION: The facet toothed plate assisted reduction method prevents facet joint dislocation and improves fracture reduction compared to traditional reduction technique, hence it could be considered as a novel surgical strategy for thoracolumbar fracture reduction.

Anti-Stress and Anti-ROS Effects of MnOx-Functionalized Thermosensitive Nanohydrogel Protect BMSCs for Intervertebral Disc Degeneration Repair.

Stem cell transplantation has been proven to be a promising strategy for intervertebral disc degeneration (IDD) repair. However, replicative senescence of bone marrow-derived mesenchymal stem cells (BMSCs), shear damage during direct injection, mechanical stress, and the reactive oxygen species (ROS)-rich microenvironment in degenerative intervertebral discs (IVDs) cause significant cellular damage and limit the therapeutic efficacy. Here, an injectable manganese oxide (MnOx)-functionalized thermosensitive nanohydrogel was proposed for BMSC transplantation for IDD therapy. The MnOx-functionalized thermosensitive nanohydrogel not only successfully protected BMSCs from shear force and mechanical stress before and after injection but also repaired the harsh high-ROS environment in degenerative IVDs, thus effectively increasing the viability of BMSCs and resident nucleus pulposus cells (NPCs). The MnOx-functionalized thermosensitive nanohydrogel provides mechanical protection for stem cells and helps to remove endogenous ROS, providing a promising stem cell delivery platform for the treatment of IDD. This article is protected by copyright. All rights reserved.

Impact of bilateral facet joint violation on radiographic degeneration of superior adjacent segments and clinical outcomes.

OBJECTIVE: Facet joint violation (FJV) is associated with postoperative low-back pain and is a confirmed risk factor for adjacent-segment degeneration, a long-term complication of lumbar fusion surgery. The authors' knowledge of its mechanisms comes from in vitro biomechanical research only; there is a lack of radiographic evidence of the effects of violation on the superior adjacent-segment facet joint, intervertebral disc, and other local radiographic parameters. Furthermore, any differences between unilateral and bilateral violation remain relatively unclear. The authors therefore aimed to explore the effects of nonviolation and unilateral and bilateral violation on radiographic degeneration of the facet joint and intervertebral disc at the fusion and superior adjacent segment. Patient-reported clinical outcomes were compared at the 2-year follow-up. METHODS: The authors retrospectively analyzed data from 148 patients with lumbar degenerative diseases who underwent single-segment minimally invasive transforaminal lumbar interbody fusion between 2016 and 2020. FJV and facet joint degeneration were evaluated and graded using Shah's method and Pathria's standard, respectively. Radiographic parameters, including disc height and intervertebral Cobb angle at the fusion and superior adjacent segment, were measured. Clinical outcomes were evaluated using visual analog scale (VAS) and Japanese Orthopaedic Association scores. RESULTS: Preoperative data were comparable among the 3 groups (nonviolation, unilateral violation, and bilateral violation) (p > 0.05). Patient-reported clinical outcomes were followed up for at least 2 years (average duration 28.17 ± 6.17 months). At the last follow-up, facet joint degeneration grades were sequentially increased in the nonviolation, unilateral violation, and bilateral violation groups (p = 0.006). The unilateral (2.45 ± 2.17 mm) and bilateral (2.70 ± 1.94 mm) violation groups had more severe losses of disc height in the superior adjacent segment than did the nonviolation group (1.31 ± 2.01 mm). The VAS low-back pain and Japanese Orthopaedic Association scores in the bilateral (2.57 ± 1.44 and 19.83 ± 2.84, respectively) and unilateral (2.26 ± 0.79 and 20.43 ± 3.85, respectively) violation groups were significantly worse than in the nonviolation group (1.69 ± 1.12 and 21.80 ± 3.36, respectively) (p < 0.05). By contrast, there were no significant between-group differences in disc height, intervertebral Cobb angle in the fusion segment, or VAS leg pain scores (p > 0.05). CONCLUSIONS: FJV was associated with postoperative low-back pain and worse functional outcomes. It also aggravated facet joint and intervertebral disc changes in the superior adjacent segment, especially when bilateral violation occurred; this may be part of the mechanisms of adjacent-segment degeneration.

Risk Factors for Surgical Treatment of Lumbar Degenerative Disc Disease in Middle-aged and Older Women: A Prospective Case-Control Study of 2370 Subjects.

OBJECTIVE: Given the distinct physiological and societal traits between women and men, we propose that there are distinct risk factors for lumbar degenerative disc disease surgeries, including lumbar disc herniation (LDH) and lumbar spinal stenosis (LSS), in middle-aged and older populations. However, few studies have focused on middle-aged and older women. This study aims to identify these risk factors specifically in this population. METHODS: In this case-control study, the study group comprised 1202 women aged ≥ 45 years who underwent operative treatment of lumbar degenerative disc disease (LDH, n = 825; LSS, n = 377), and the control group comprised 1168 women without lumbar disease who visited a health examination clinic during the same period. The study factors included demographics (age, body mass index [BMI], smoking, labor intensity, and genetic history), female-specific factors (menopausal status, number of deliveries, cesarean section, and simple hysterectomy), surgical history (number of abdominal surgeries, hip joint surgery, knee joint surgery, and thyroidectomy), and systemic diseases (hypercholesterolemia, hypertriglyceridemia, hyper-low-density lipoprotein cholesterolemia, hypertension, diabetes, cardiovascular disease, and cerebrovascular disease). Multivariate binary logistic regression analysis was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) of associated factors. RESULTS: The risk factors for surgical treatment of LDH in middle-aged and older women included BMI (OR = 1.603), labor intensity (OR = 1.189), genetic history (OR = 2.212), number of deliveries (OR = 1.736), simple hysterectomy (OR = 2.511), hypertriglyceridemia (OR = 1.932), and hyper-low-density lipoprotein cholesterolemia (OR = 2.662). For surgical treatment of LSS, the risk factors were age (OR = 1.889), BMI (OR = 1.671), genetic history (OR = 2.134), number of deliveries (OR = 2.962), simple hysterectomy (OR = 1.968), knee joint surgery (OR = 2.527), hypertriglyceridemia (OR = 1.476), hyper-low-density lipoprotein cholesterolemia (OR = 2.413), and diabetes (OR = 1.643). Cerebrovascular disease was a protective factor against surgery for LDH (OR = 0.267). CONCLUSIONS: BMI, genetic history, number of deliveries, simple hysterectomy, hypertriglyceridemia, and hyper-low-density lipoprotein cholesterolemia were independent risk factors for surgical treatment of both LDH and LSS in middle-aged and older women. Two disparities were found: labor intensity was a risk factor for LDH patients, and knee joint surgery and diabetes were risk factors for LSS patients.

Piezo1 channel exaggerates ferroptosis of nucleus pulposus cells by mediating mechanical stress-induced iron influx.

To date, several molecules have been found to facilitate iron influx, while the types of iron influx channels remain to be elucidated. Here, Piezo1 channel was identified as a key iron transporter in response to mechanical stress. Piezo1-mediated iron overload disturbed iron metabolism and exaggerated ferroptosis in nucleus pulposus cells (NPCs). Importantly, Piezo1-induced iron influx was independent of the transferrin receptor (TFRC), a well-recognized iron gatekeeper. Furthermore, pharmacological inactivation of Piezo1 profoundly reduced iron accumulation, alleviated mitochondrial ROS, and suppressed ferroptotic alterations in stimulation of mechanical stress. Moreover, conditional knockout of Piezo1 (Col2a1-CreERT Piezo1flox/flox) attenuated the mechanical injury-induced intervertebral disc degeneration (IVDD). Notably, the protective effect of Piezo1 deficiency in IVDD was dampened in Piezo1/Gpx4 conditional double knockout (cDKO) mice (Col2a1-CreERT Piezo1flox/flox/Gpx4flox/flox). These findings suggest that Piezo1 is a potential determinant of iron influx, indicating that the Piezo1-iron-ferroptosis axis might shed light on the treatment of mechanical stress-induced diseases.

A statistical symptomatic evaluation on SAPHO syndrome from 56 cases of confirmed diagnosis and 352 cases of non-SAPHO involvement.

OBJECTIVE: To report a statistical evaluation of symptomatology based on 56 cases of SAPHO syndrome and 352 non-SAPHO involvement cases, to propose a symptomatic scoring system in consideration of early warning for SAPHO syndrome. METHODS: A cohort comprising 56 subjects diagnosed with SAPHO syndrome was reported, as well as 352 non-SAPHO involvement cases, including their chief complaints, skin manifestations, radiological findings, and laboratory tests. We systematically reviewed previous published five representative huge cohorts from different countries to conclude several specific features of SAPHO by comparing with our case series. The score of each specific index is based on respective incidence and comparison of two cohorts was performed. RESULT: In terms of complaint rates, all subjects of two cohorts suffered from osseous pain, which appeared in the anterior chest wall, spine, and limb which were calculated. In respect to dermatological lesions, SAPHO patients suffered from severe acne, and other patients (82.14%) accompanied with palmoplantar pustulosis. Having received radiological examinations, most SAPHO subjects rather than non-SAPHO involvement cases showed abnormal osteoarticular lesions under CT scanning and more detailed information under whole-body bone scintigraphy. Differences also emerged in elevation of inflammation values and rheumatic markers like HLA-B27. Based on our cases and huge cohorts documented, the early warning standard is set to be 5 scores. CONCLUSIONS: SAPHO syndrome case series with 56 subjects were reported and an accumulative scoring system for the early reminder on SAPHO syndrome was proposed. The threshold of this system is set to be 5 points. Key Points • Fifty-six patients diagnosed by SAPHO syndrome with detailed symptoms and radiological findings were reported. • Comparison was made between the 56 SAPHO patients and 352 non-SAPHO involvement cases. • An accumulative scoring system for the early reminder on SAPHO syndrome was proposed and the threshold of this system is set to be five points.

Comparison of Clinical and Radiographic Outcomes Between Transforaminal Endoscopic Lumbar Discectomy and Microdiscectomy: A Follow-up Exceeding 5 Years.

OBJECTIVE: To compare the long-term clinical and radiographic outcomes of transforaminal endoscopic lumbar discectomy (TELD) versus microdiscectomy (MD). METHODS: The data of 154 patients with lumbar disc herniation (LDH) who underwent TELD (n = 89) or MD (n = 65) were retrospectively analyzed. The patients' clinical outcomes were evaluated using visual analogue scales for leg and low back pain, the Japanese Orthopaedic Association (JOA) score, and the Oswestry Disability Index (ODI). The evolution of radiographic manifestations was observed during follow-up. Potential risk factors for a poor clinical outcome were investigated. RESULTS: During a mean follow-up of 5.5 years (range, 5-7 years), the recurrence rate was 4.49% in the TELD group and 1.54% in the MD group. All scores significantly improved from preoperatively to postoperatively in both groups (p < 0.01). The improvement in the ODI and JOA scores was significantly greater in the TELD than MD group (p < 0.05). Forty-seven patients (52.8%) in the TELD group and 32 (49.2%) in the MD group had Modic changes before surgery, most of which showed no changes at the last follow-up. The degeneration grades of 292 discs (71.0%) were unchanged at the last follow-up, while 86 (20.9%) showed improvement, mostly at the upper adjacent segment. No significant difference was observed in the intervertebral height index or paraspinal muscle-disc ratio. CONCLUSION: Both TELD and MD provide generally satisfactory long-term clinical outcomes for patients with LDH. TELD can be used as a reliable alternative to MD with less surgical trauma. Modic type II changes, decreased preoperative intervertebral height, and a high body mass index are predictors of a poor prognosis.

Novel Modic grading scoring system and its clinical validation: a preliminary investigation.

PURPOSE: To propose a novel Modic grading scoring system and explore the relationship between the Modic grading score and disc degeneration, disc herniation, disc height, and clinical symptom scores. METHOD: In total, 194 patients were included in the study. The new Modic grading scoring system included four indicators: invaded vertebral height, invaded endplate length, endplate morphology, and grade of endplate defects. The severity of Modic changes was visually quantified by numerical scores, and the kappa value was used to verify the interobserver and intraobserver reliability. Spearman correlation analysis was used to explore the relationship between the Modic grading score and intervertebral disc degeneration, disc herniation, disc height, and clinical symptom scores. RESULTS: The interobserver and intraobserver reliability showed substantial to almost perfect agreement in the new Modic grading scoring system. The Modic grading score was positively correlated with intervertebral disc degeneration (r = 0.757, p < 0.001) and negatively correlated with the intervertebral disc height index (r = - 0.231, p < 0.001). There was no significant correlation between the Modic grading scoring system and disc herniation (r = 0.369, p = 0.249). Additionally, there was no significant correlation between the Modic grading score and the Japanese Orthopaedic Association score (r = - 0.349, p = 0.25), Oswestry Disability Index score (r = 0.246, p = 0.11), or visual analogue scale score (r = 0.315, p = 0.35). CONCLUSION: The new Modic grading scoring system had good interobserver and intraobserver reliability. The Modic grading score was positively correlated with intervertebral disc degeneration and negatively correlated with the intervertebral disc height.

Effect of Topical Nonsteroidal Anti-inflammatory Drugs Around the Incision on Postoperative Pain in Transforaminal Lumbar Interbody Fusion Surgery: A Double-blind Randomized Controlled Trial.

BACKGROUND: How to minimize postoperative pain following spinal surgery has been a great challenge. We hypothesized that topical nonsteroidal anti-inflammatory drugs (NSAIDs) around the incision could relieve postoperative pain following transforaminal lumbar interbody fusion (TLIF) surgery. OBJECTIVE: This study tested the effect of topical NSAIDs around the incision for pain management after TLIF surgery. STUDY DESIGN: A double-blind randomized controlled trial. SETTING: Qilu Hospital of Shandong University. METHODS: Eighty patients who underwent single-level TLIF surgery were randomized into 2 groups. The treatment group received postoperative topical NSAIDs around the incision. The control group received a postoperative topical placebo around the incision. All patients in both groups received postoperative patient-controlled analgesia (PCA) via an analgesia pump. The primary outcome measures were the amount of opioid consumption and pain measurement via the visual analog scale (VAS). The secondary outcome measures were the time of first analgesic demand, operation time, postoperative drain output, side effects of opioids, postoperative stay, and Oswestry Disability Index (ODI) score. RESULTS: The consumption of opioids in the treatment group was significantly less than in the control group at postoperative 12 hours, 12 to 24 hours, and 24 to 48 hours (P < 0.005). The VAS in the treatment group was significantly lower than those in the control group at all assessment times within 72 hours postoperative (P < 0.005). The time of first analgesic demand of PCA in the treatment group was significantly longer than that in the control group (P < 0.005). The side effects of opioids were significantly less in the treatment group than in the control group (P < 0.05). There was no significant difference in operation time, postoperative drain output, postoperative stay, and ODI between the 2 groups (P > 0.05). LIMITATIONS: This was a single-center study for single-level TLIF surgery. CONCLUSION: Postoperative topical NSAID around the incision is a highly effective and safe method for postoperative pain management following single-level TLIF surgery. In our study it reduced postoperative opioid requirements and prolonged the time of first analgesic demand with no increased side effects. KEY WORDS: Transforaminal lumbar interbody fusion, postoperative pain, NSAID, topical NSAID, nonsteroidal anti-inflammatory drug, loxoprofen.

Pentraxin 3 deficiency ameliorates the severity of osteoarthritis and alleviates inflammation.

BACKGROUND: Osteoarthritis is one of the most common degenerative joint disorders, characterized by articular cartilage breakdown, synovitis, osteophytes generation and subchondral bone sclerosis. Pentraxin 3 (PTX3) is a long pentraxin protein, secreted by immune cells, and PTX3 is identified to play a critical role in inflammation and macrophage polarization. However, the underlying mechanism of PTX3 in osteoarthritis under the circumstance of Ptx3-knockout (KO) mice model is still unknown. METHODS: Murine destabilization of the medial meniscus (DMM) OA model was created in Ptx3-knockout (KO) and wildtype mice, respectively. The degenerative status of cartilage was detected by Safranin O, H&E staining, immunohistochemistry (IHC) and micro-CT. OARSI scoring was employed to assess the proteoglycan of cartilage. Serum inflammatory cytokines were examined by ELISA and systematic macrophage polarization in spleen was analyzed by flow cytometry. RESULTS: Safranin O and H&E staining confirmed that the joint cartilage was mostly with reduced degeneration in both the senior KO mice and the DMM model generated from the KO mice, compared to the WT group. This is also supported by micro-CT examination and OARSI scoring. Immunohistochemistry illustrated an up-regulation of Aggrecan and Collagen 2 and down-regulation of ADAMTS-5 and MMP13 in KO mice in comparison with the WT mice. ELISA indicated a dramatical decrease in the serum levels of TNF-α and IL-6 in KO mice. Polarization of M2-like macrophages was observed in the KO group. CONCLUSION: Pentraxin 3 deficiency significantly ameliorated the severity of osteoarthritis by preventing cartilage degeneration and alleviated systematic inflammation by inducing M2 polarization.

Variants in the SOX9 transactivation middle domain induce axial skeleton dysplasia and scoliosis.

SOX9 is an essential transcriptional regulator of cartilage development and homeostasis. In humans, dysregulation of SOX9 is associated with a wide spectrum of skeletal disorders, including campomelic and acampomelic dysplasia, and scoliosis. The mechanism of how SOX9 variants contribute to the spectrum of axial skeletal disorders is not well understood. Here, we report four novel pathogenic variants of SOX9 identified in a large cohort of patients with congenital vertebral malformations. Three of these heterozygous variants are in the HMG and DIM domains, and for the first time, we report a pathogenic variant within the transactivation middle (TAM) domain of SOX9 . Probands with these variants exhibit variable skeletal dysplasia, ranging from isolated vertebral malformation to acampomelic dysplasia. We also generated a Sox9 hypomorphic mutant mouse model bearing a microdeletion within the TAM domain ( Sox9 Asp272del ). We demonstrated that disturbance of the TAM domain with missense mutation or microdeletion results in reduced protein stability but does not affect the transcriptional activity of SOX9. Homozygous Sox9 Asp272del mice exhibited axial skeletal dysplasia including kinked tails, ribcage anomalies, and scoliosis, recapitulating phenotypes observed in human, while heterozygous mutants display a milder phenotype. Analysis of primary chondrocytes and the intervertebral discs in Sox9 Asp272del mutant mice revealed dysregulation of a panel of genes with major contributions of the extracellular matrix, angiogenesis, and ossification-related processes. In summary, our work identified the first pathologic variant of SOX9 within the TAM domain and demonstrated that this variant is associated with reduced SOX9 protein stability. Our finding suggests that reduced SOX9 stability caused by variants in the TAM domain may be responsible for the milder forms of axial skeleton dysplasia in humans.

Comparative study of preoperative sagittal alignment between patients with multisegment cervical ossification of the posterior longitudinal ligament and cervical spondylotic myelopathy.

BACKGROUND CONTEXT: Preoperative sagittal alignment is of great significance in the development of spinal deformities, degenerative diseases, preoperative planning, postoperative clinical evaluation, and functional recovery. However, few reports have focused on the difference in preoperative sagittal alignment between patients with ossification of the posterior longitudinal ligament (OPLL) and patients with cervical spondylotic myelopathy (CSM). PURPOSE: To compare preoperative sagittal alignment between patients with multisegment cervical OPLL and multilevel CSM. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: A total of 243 patients were included in this study. OUTCOME MEASURES: The outcome measures were the Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, number of hand actions in 10 seconds, hand-grip strength, C2 to C7 Cobb angle, C2 to C5 Cobb angle, C5 to C7 Cobb angle, C2 to C7 sagittal vertical axis, C7 slope, T1 slope, K-line, K-line tilt, and range of motion (ROM). METHODS: The outcome measures were calculated in the OPLL group and CSM group and the data were analyzed using the unpaired t-test, χ² test, and one-way analysis of variance. RESULTS: A total of 243 patients (136 men, 107 women; mean age, 59.1±10.6 years) underwent surgical treatment from September 2013 to December 2021. In total, 123 patients were diagnosed with multisegment cervical OPLL, including continuous type (n=39), segmental type (n=38), and mixed type (n=46). The remaining 120 patients had multisegment CSM. The disease course in the OPLL group was significantly shorter than that in the CSM group (p<.05). Among the above preoperative measurements, the JOA score, number of hand actions in 10 seconds, hand-grip strength, and VAS score were not significantly different between the two groups (p>.05). The C2 to C7 Cobb angle was significantly larger in the OPLL than CSM group (17.7°±9.2° and 14.9°±9.3°, respectively; p< .05), as was the C5 to C7 Cobb angle (10.0°±6.3° and 7.5°±6.1°, respectively; p<.05). The ROM was significantly smaller in the OPLL than CSM group (33.1°±8.1° and 40.1°±10.9°, respectively; p<.001). Within the OPLL group, the ROM was significantly smaller in the continuous type than in the segmental type (p<.05). CONCLUSION: Patients with multisegment cervical OPLL have greater lordotic preoperative sagittal alignment and smaller preoperative ROM than patients with CSM.

Safety and accuracy of cannulated pedicle screw placement in scoliosis surgery: a comparison of robotic-navigation, O-arm-based navigation, and freehand techniques.

PURPOSE: To compare the safety and accuracy of cannulated pedicle screw placement using a robotic-navigation technique, O-arm-based navigation technique, or freehand technique. METHODS: This study analyzed 106 consecutive patients who underwent scoliosis surgery. Thirty-two patients underwent robotic-navigation-assisted pedicle screw insertion (Group 1), 34 patients underwent O-arm-based navigation-guided pedicle screw insertion (Group 2), and 40 patients underwent freehand pedicle screw insertion (Group 3). The primary outcome measure was the accuracy of screw placement. Secondary outcome parameters included operation time, blood loss, radiation exposure, and postoperative stay. RESULTS: A total of 2035 cannulated pedicle screws were implanted in 106 patients. The accuracy rate of the first pedicle screw placement during operation was significantly greater in Group 1 (94.7%) than in Group 2 (89.2%; P < 0.001). The accuracy rate of pedicle screw placement postoperatively decreased in the order of Group 1 (96.7%) > Group 2 (93.0%) > Group 3 (80.4%; P < 0.01). There were no significant differences in blood loss or postoperative stay among the three groups (P > 0.05). The operation times of Group 1 and Group 2 were significantly longer than that of Group 3 (P < 0.05). CONCLUSION: The robotic-navigation and O-arm-based navigation techniques effectively increased the accuracy and safety of pedicle screw insertion alternative to the freehand technique in scoliosis surgery. Compared with the O-arm-based navigation technique, the robotic-navigation technique increases the mean operation time, but also increases the accuracy of pedicle screw placement. A three-dimensional scan after insertion of the K-wire may increase the accuracy of pedicle screw placement in the O-arm-based navigation technique.

Retrospective Analysis of Associated Anomalies in 636 Patients with Operatively Treated Congenital Scoliosis.

BACKGROUND: Congenital scoliosis is frequently associated with anomalies in multiple organ systems. However, the prevalence and distribution of associated anomalies remain unclear, and there is a large amount of variation in data among different studies. METHODS: Six hundred and thirty-six Chinese patients who had undergone scoliosis correction surgery at Peking Union Medical College Hospital from January 2012 to July 2019 were recruited, as a part of the Deciphering disorders Involving Scoliosis and COmorbidities (DISCO) study. The medical data for each subject were collected and analyzed. RESULTS: The mean age (and standard deviation) at the time of presentation for scoliosis was 6.4 ± 6.3 years, and the mean Cobb angle of the major curve was 60.8° ± 26.5°. Intraspinal abnormalities were found in 186 (30.3%) of 614 patients, with diastematomyelia being the most common anomaly (59.1%; 110 of 186). The prevalence of intraspinal abnormalities was remarkably higher in patients with failure of segmentation and mixed deformities than in patients with failure of formation (p < 0.001). Patients with intraspinal anomalies showed more severe deformities, including larger Cobb angles of the major curve (p < 0.001). We also demonstrated that cardiac anomalies were associated with remarkably worse pulmonary function, i.e., lower forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF). Additionally, we identified associations among different concomitant malformations. We found that patients with musculoskeletal anomalies of types other than intraspinal and maxillofacial were 9.2 times more likely to have additional maxillofacial anomalies. CONCLUSIONS: In our cohort, comorbidities associated with congenital scoliosis occurred at a rate of 55%. To our knowledge, our study is the first to show that patients with congenital scoliosis and cardiac anomalies have reduced pulmonary function, as demonstrated by lower FEV1, FVC, and PEF. Moreover, the potential associations among concomitant anomalies revealed the importance of a comprehensive preoperative evaluation scheme. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Anterior cervical tunnectomy and fusion (ACTF): a novel technique for cervical canal decompression.

OBJECTIVE: To describe a novel surgical technique note coined as anterior cervical tunnectomy and fusion (ACTF) which applying on removal of posterior vertebral bony protrusions or soft extrusions. METHODS: Total twenty-three patients from January 2016 to January 2021 who experienced with spinal cord compression and performed by ACTF were retrospectively reviewed. Herein, relevant information including patient's gender, age, BMI, intraoperative time, intraoperative blood loss, postoperative complications and postoperative hospitalized stay were collected. Furthermore, JOA and VAS score were both collected. Moreover, imaging parameters were measured and calculated on radiographs. Correlated data were analyzed by t test. Significance was considered when P < 0.05. RESULTS: All patients in this study were validated with favorable outcomes and none of postoperative complications. The Nurick grade of patients dramatically deceased postoperation (P < 0.001). And postoperative VAS score of patients (P < 0.001), as well as JOA score (P < 0.001), was given dramatical significance comparing to preoperation. Furthermore, occupying rate (OR) (P < 0.001) was obviously reduced while space available cord (SAC) (P < 0.001) and diameter of spinal cord (P < 0.001) was significantly increased postoperation. Meanwhile, disc height of involved segment, C2-7 SVA, and C2-C7 Cobb angle were measured on sagittal plane of lateral radiograph. Postoperative disc height of involved segment (P < 0.001) significantly elevated comparing to preoperation. However, there were no significance on C2-7 SVA (P = 0.460) and C2-C7 Cobb angle (P = 0.097). CONCLUSIONS: The novel surgical technique coined by ACTF is a practicable approach during taking charge of bony and soft narrowing behind vertebral space.